1. HRCT IN DETECTION OF NTM PULMONARY INFECTION IN IMMUNOCOMPETENT PATIENTS: OUR EXPERIENCE.
T.Valente, M.Marino, G.Rea, A.Di Matteo, S. Urciuolo, R.Muto
Department of Radiology, Monaldi Hospital, Naples, Italy

2. NTM Infection
a group of low-grade pathogens omnipresent in the environment (water, soil, milk, fish, birds, animals)
mode of transmission : inhalation, ingestion, direct inoculation, human-to-human (rare); main source of pulmonary infection water vapour
In hospital setting infection may originate from biofilm sources (bronchoscopes)
Preexisting disease: smoking-related COPD, bronchiectasis, pneumoconiosis, diabetes mellitus, alcohol abuse, localized pulmonary fibrosis, INF-gamma deficit, cystic fibrosis
Clinical presentation is variable and non specific, the level of host immunity has a profound effect on the severity of infection
CHEST 2004; 126:566-81
RADIOLOGY 2004; 231:880-86
RADIOLOGY 2005; 235:282-88
AM J RESP CRIT CARE MED 1997; 156:S21-25
RADIOGRAPHICS 1999; 19:
Group
Name
Characteristics I
Photochromogens
Colonies require 2–4 weeks to grow in culture and change from colorless to yellow on exposure to light; M kansasii is the most common pulmonary pathogen in this group II
Scotochromogens
Colonies require 2–4 weeks to grow in culture and change from yellow to orange on exposure to light; these organisms (M gordonae, M szulgai) are rare pulmonary pathogens
III
Nonphotochromogens
Colonies require 2–4 weeks to grow in culture, are beige or white, and do not change color on exposure to light; this group includes M avium-intracellulare (the most common pulmonary pathogen) and M xenopi IV
The rapid growers
Colonies are visible after 3–5 days of culture and do not change color on exposure to light; these organisms (M fortuitum, M chelonae) are uncommon pulmonary pathogens
Runyon Classification

3. Purposes of the Study Estimate imaging (CXR, HRCT) at diagnosis
Understand diagnostic utility of conventional radiographic abnormalities
Characterize HRCT dominant patterns of infection
Imaging –pathologic correlation
Follow-up of the lesions encountered at radiological presentation

4. ATS/IDSA criteria 2007 for diagnosis of pulmonary NTM diseases
MATERIALS
ATS/IDSA criteria 2007 for diagnosis of pulmonary NTM diseases
Clinical and radiographic (both required): Pulmonary symptoms, nodular or cavitary opacities on chest radiograph, or a HRCT scan AND Appropriate exclusion of other diagnoses, especially tuberculosis and mycosis
Microbiological Positive culture results from at least two separately expectorated sputum samples. If results are non-diagnostic, consider repeat smears and cultures
OR Positive culture results from at least one bronchial wash or lavage OR  Transbronchial or other lung biopsy with mycobacterial histopathological features (granulomatous inflammation or stainable acid-fast bacilli), positive culture for NTM or biopsy showing mycobacterial histological features, and ≥1 sputum or bronchial washings that are culture positive for NTM. 
We retrospectively reviewed the CXR and HRCT examinations (HRCT, slice thickness 1mm/interslice 10mm, bone filter) performed between
Jan ’02- Dic ’08,
on 56 immunocompetent patients (M/F-37/19; age range ys) with diagnosis of NTM pulmonary infection confirmed by using American Thoracic Society criteria
Am. J. Respir. Crit. Care Med. 2007

5. METHODS EVALUATED FINDINGS HRCT CXR Cavitations
Foci of consolidations
Small diffuse nodules
Bronchiectasis
Fibrosis with lobar volume loss
Focal pleural thickening
Mediastinal adenopathy
Pleural effusion
HRCT
Small nodules (Ø ‹ 10mm)
Nodules (Ø 10-30mm)
Tree in bud
Foci of consolidations
Bronchiectasis
Cavitary disease
Pleural thickening
Adenopathy
15/ follow up after therapy up to 20 months
4/ correlation radiologic/pathologic on reseceted
lobectomy gross specimens

6. 33/56 M. Kansasii (M/F-23/10; age 55-83ys)
RESULTS
33/ M. Kansasii (M/F-23/10; age 55-83ys)
23/ MAC (M/F-9/14; age 41-72ys)
CT characterized 2 lobar consolidations, 10 segmental consolidations, 8 cavitated lesions,and 12 bronchiectasis areas not showed at CXR.
CT FINDINGS
RUL ML
RLL
LUL
LING
LLL
SMALL NODULES
14(26,5%)
11(20,1%)
5(9,5%)
9(17%)
NODULES
8(31,6%)
4(15,8%)
5(21%)
3(10,5%)
2(5,3%)
SEGM. CONSOL.
9(25%)
6(17,8%)
5(14,3%)
10(31,1%)
LOBAR CONSOL.
3(30%)
0(0%)
2(20%)
TREE-IN-BUD
8(41,2%)
6(29,4%)
4(23,5%)
3(11,8%)
CAVITATION
16(46,6%)
6(16,7%)
5(16,7%)
4(13,3%)
2(6,7%)
3(10%)
BRONCHIECTASIS
8(25%)
7(21,4%)
1(3,6%)
2(7,1%)
3(7,1%)
3(10,7%)

8. 2 patients: “hot tub lung” pattern
contaminated water in hot tub is aerosolized and inhaled causing hypersensitivity reaction (or a granulomatous response to infection? Maybe both processes)
occurs in previously healthy subjects
radiologic findings are typical of hypersensitivity pneumonitis
Primarily to aerosolized M. avium-intracellulare
radiographs show fine diffuse reticulonodular or miliary pattern
CT shows patchy areas of ground glass attenuation and/or poorly formed nodules of ground glass attenuation. Expiratory images may show airtrapping indicating an associated bronchiolitis

9. Hot tub lung 1: miliary form (small nodules 1-2 mm) with lamellar consolidations

10. Hot tub lung 2:
poorly formed GGO micronodules
Expiratory
air trapping

11. CONSIDERATIONS SMALL NODULES 78.6% CAVITATIONS 71.4%
BRONCHIECTASIS %
SEGMENT.CONSOLID %
NTM
SMALL NODULES
BRONCHIECTASIS
CAVITATION
M.Kansasii
30-39% upper lobe
30% right upper lobe
43% upper lobe
MAC
50% middle lobe and lingula
30-50% middle lobe and lingula
33.3% middle lobe and lingula
SMALL NODULES 70%
CAVITATIONS 20%
BRONCHIECTASIS 80%
SEGMENT. CONSOLID. 75%
(E.H.Moore RADIOLOGY 1993)
SMALL NODULES 87%
CAVITA’TIONS 13%
BRONCHIECTASIS %
SEGMENT. CONSOLID %
(Y.J.Jeong RADIOLOGY 2004)

12. small nodules
consolidation
bronchiectasis
cavitation
macronodules

13. RESULTS Follow up 15/56 8 MAC / 7 M. Kansasii
5/15 nodule cavitation (2 right upper lobe; 1 lingula; 1 middle lobe)
6/15 new bronchiectasis and increased number of preexisting
3/15 small nodules, consolidations and tree-in-bud reduction
2/15 unchanged pattern
4/15 disease progression – surgical treatment (lobectomy)
Centrilobular nodules correspond to granulomas and caseous material at the level of the terminal and respiratory bronchioles; nodules > 10mm and lobar consolidation correspond to areas of central caseous granulomas, associated with nonspecific marginal inflammation and lymphocyte infiltration, which completely replaces the alveolar spaces. The wall of the cavitations consists of caseous material, epithelioid cells, multinucleated giant cells, granulomatous tissue and a fibrotic capsule.

14. 18 months
day 0
18 months
day 0

15. CONCLUSIONS (1/3) More frequent pattern in immunocompetent:
Diffuse small nodules
bronchiectasis
Segmental aonsolidation
cavitations
“CLASSIC” fibrocavitary form *
of upper lobes is more prevalent among older men with underlying chronic pulmonary disease, most cases are caused by M. Kansasii
* J.J.Erasmus RADIOGRAPHICS 1999
* S.Field CHEST 2004
Some of these patients may voluntarily suppress their cough, leading to poor drainage of secretions and engraftment of NTM, the so-called Lady Windermere syndrome*
*Reich JM CHEST 1992
“Nodular -bronchiectatic (Nonclassic) Form*
of middle lobe/lingula is more commonly seen among middle-aged /elderly women with no predisposing factors,
most cases are caused by MAC
* J.J.Erasmus RADIOGRAPHICS 1999
* S.Field CHEST 2004

16. CONCLUSIONS (2/3) Less frequent pattern in immunocompetent:
Hypersensitivity pneumonitis –like (hot tube)
Solitary pulmonary nodule
presents very much like a tuberculoma, and has to be differentiated from a carcinoma
Solitary pulmonary nodule

17. BRONCHIECTASIS: CAUSE AND/OR EFFECT!!!!!!
CONCLUSIONS (3/3)
New nodules occur over time
Some macronodules can undergo cavitation
Some small nodules may disappear
Preexisting bronchiectasis tend to increase in size
New areas of dilatation can form over time
BRONCHIECTASIS: CAUSE AND/OR EFFECT!!!!!!

18. THANK YOU !!!!!

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